Sympathetic nerve blockade for ventricular arrhythmias: stellate ganglion and beyond

To review and summarize the current clinical evidence supporting sympathetic neural blockade for recurrent and refractory ventricular arrhythmias and electrical storm. These conditions continue to be associated with substantial morbidity and mortality, despite advances in antiarrhythmic therapy, catheter ablation, and mechanical circulatory support. Sympathetic overactivity is a key driver of ventricular arrhythmogenesis, and cardiac autonomic neuromodulation should be recognized as an important tool in the therapeutic algorithms.

Clinical evidence and acceptance of percutaneous and neuraxial sympathetic blockade for ventricular tachyarrhythmias and electrical storm are rapidly accumulating. A dramatic increase in the amount of peer-reviewed publications indicates a transition from emergence and recognition to mainstream adoption and consolidation phases.Currently, most reports and strongest evidence support percutaneous stellate ganglion block (SGB), associated with rapid reductions in ventricular arrhythmia episodes and implantable cardioverter defibrillator shocks across systematic reviews and multicenter observational studies. Continuous block techniques may prolong benefit beyond a single-injection. Thoracic epidural anesthesia has also demonstrated clinically meaningful arrhythmia suppression, while evidence for thoracic paravertebral and proximal intercostal blocks is accumulating.

Sympathetic neural blockade is a clinically effective adjunct therapy for refractory ventricular arrhythmias, with SGB currently supported by the strongest clinical evidence.